Monday, May 21

Also known as Congenital Dermal Melanocytosis, Mongolian blue spot, is a benign asymptomatic birthmark present at birth or appears shortly thereafter. It is also known as Mongolian spot and Mongolian birthmark.

This pigmented macule is flat and irregular in shape with wavy and indistinct border. Mongolian condition is usually present as multiple patches or one single large patch in lumbosacral area and buttocks; it may also occur on shoulders and other parts of the body, usually sparing head, face, palms and soles.

The Mongolian spot spontaneously regresses, fades and disappears by the age of 3 or 4 years. It rarely persist up to puberty. As this macule is harmless and disappears on its own, no treatment is necessary. Blue and blue-green are the most common colors. However grey, slate-grey, blue-grey, grey-black and brown coloration are also encountered.

This Mongolian condition is congenital in origin and involves skin. The blue skin discoloration is due to dense presence of melanocytes, the pigment cells containing melanin. Though normally melanocytes are present in epidermal layer of skin, in these Mongolian spots, they are present in deeper dermis layer of skin. Histological studies reveal the presence of widely placed dendritic melanocytes in lower reticular dermis. These melanocytes are found between bundles of collagen. In contrast to blue nevus wherein the dermis is fibrotic, the collagen is unaltered in Mongolian spot.

Erwin Bälz (13 January 1849 – 31 August 1913) discovered and named "Mongolian spot". He was a German and was a personal physician to the Japanese Imperial Family. He was the founder of modern medicine in Japan. He thought that the blue macules found in Japanese babies are characteristics of the Mongoloid races and called them Mongolian spots.

However Mongolian macule is highly prevalent among people of East and South-east Asian origin, East Africans and Native Americans (85-100%). People of Turkish and Hispanic origins also have high degree of prevalence (50-70%). It is rarer among Caucasian (1-10%) and other races. Mongolian pigment condition is unrelated to gender and both female and male infants are equally predisposed. Sometimes Mongolian spot may be mistaken for bruise due to child abuse.

Neural crest, melanocytes and Mongolian spot

A brief knowledge of fetal development is necessary for understanding how Mongolian blue spot is formed. During gastrulation stage, fetus undergoes massive reorganisation by the processes called invagination, ingression and involution. From being a spherical ball of cells (blastula) it is transformed into multilayer organism. Now a neural plate is formed by thickening of the ectoderm layer. The edges of the plate fold and raise to meet at the middle to form neural tube and epidermis. the cells at the tips of the neural folds and adjoining epidermis form neural crest cells.

Neural crest is a pluripotent population of transient cells with multiple fates. They detach and migrate extensively throughout the fetus. Stopping at different locations, these pluripotent cells give rise to a wide array of derivatives. Some of these cells become melanocytic progenitors, getting restricted to melanogenic lineage, due to the process of melanoblast specification by various transcription factors and extracellular signalling pathways. These melanocytic progenitors are also known as melanoblasts and are unpigmented. However they have potential to produce melanin. During their migration from neural crest to epidermis, some of these melanoblasts get entrapped in dermis layer, transform to melanocytes and start producing melanin. The melanin pigment in deeper dermal areas of skin gives the blue colored appearance of Mongolian spot.

Many skin rash conditions like dermatitis, acne, psoriasis, hives, eczema, rosacea, alopecia and trichotillomania have their roots in some emotional or psychological stress. Further mental trauma can aggravate the existing rash causing flare-ups. Now a cycle develops wherein emotional disturbances develop and worsen skin problems, and then the rash leads to more stress.

Stress response is relative and the response to a similar situation can vary widely among individuals, being traumatic to some and being neutral or pleasant to others. In our lives stress has become an ubiquitous presence, insidiously affecting the quality of our life by undermining our physical and mental health.

Skin-psyche connection and psychodermatology

The skin-psyche connection was well analysed by Dr.Richard G. Fried, M.D., Ph.D., FAAD, a dermatologist and clinical psychologist, in his presentation at the Summer Academy Meeting 2011 in New York, at the American Academy of Dermatology. He emphasised the need for stress management during treatment for skin rash problems.

Psychodermatology is the latest branch of dermatology addressing the stress - skin connection in dermatological therapies. The mind and body are intricately connected. All our organs including skin are well connected by nerve endings linked to the brain. Emotional disturbances like anger, depression, distress, anxiety and tension send out neurological trauma signals to the body and the target organs may happen to be either head (headache), heart (hypertension, palpitation), gastrointestinal tract (stomach problems) or skin (rash problems).

For patients with dermal affliction an integrated approach to relieve stress as well as to reduce the rash is very helpful, making them feel better. It allows for depression treatment, relaxation therapy and also counselling to alleviate the anxiety and mood issues, while simultaneously treating the rash problems.
When the stress is episodic and the skin rash comes and goes, there is practically nothing much need to be done except taking a positive approach for this problem. When the mental agony is chronic, behavioural and social issues have to be addressed.

There are also some skin manifestations of true psychiatric problems, including skin picking and cutting, nail biting, hair pulling and delusional parasitosis. Apart from treating the skin rash and damages, such situations require psychiatric treatment. Disfiguring skin maladies, damages and blemishes can bring up self-esteem issues and lead to depression, requiring psychiatric help.

Skin as target organ of stress

When a person is anxious, stress hormones including cortisol and testosterone are released inducing the excess secretion of oil glands. Mental distress also affects the immune system and antioxidant production. Free radicals and pathogenic microorganisms have a free run. The combined effect causes flare-up of problems like pimples, acne and rash.

Neuropeptides are released by skin's nerve endings as an usual response to infection or injury. This is the first line of defence and neuropeptides cause skin sensitivity, rash and inflammation. Mental problems causes these neuropeptides to be erroneously released causing dermal flare-up problems. Further these neuropeptides move to the brain and enhance the re uptake of neurotransmitters. Mental trauma depletes the emotion regulating neurotransmitters like dopamine, noradrenaline and serotonin.

Stress affects the skin barrier function, dehydrating the dermal layers, allowing allergens and pathogens to penetrate the skin and cause rash. Mental distress can worsen rash acne, rosacea, hives,herpes infections, psoriasis, eczema and seborrheic dermatitis. There is a connection between triggering of autoimmunity problems like vitiligo and high degree of mental trauma.

Stress management for skin problems

In addition to conventional dermatological therapies, appropriate strategies for managing distress must be taken for fighting stress-induced-aggravated dermatological problems. Psychiatric treatment methods like antidepressants, beta blockers, behavioral therapy, cognitive therapy, psychotherapy, biofeedback, meditation, hypnotic techniques, relaxation techniques, massage and yoga exercises can be tried to make the patient attain mental equilibrium. Imbibing the confidence that he can overcome the dermal problems will make him to take control of his mind and body and break free from the rash and anxiety cycle.

Some of the effects of emotional trauma are premature aging, fine lines, wrinkles, dull and dehydrated skin. sound sleep and actively practicing relaxation for short spells through out the day will give serene mind and positive attitude, keeping stress and connected skin problems and rash at bay.

Saturday, May 5

In the treatment of Raynaud's phenomenon, the first step is to immediately remove the causative factors. For cure of Raynaud's disease, all possible steps to remove vasoconstriction and to promote vasodilation must be taken.

The aim of the treatment is to reduce the severity and frequency of Raynaud's incidences and to prevent tissue damage, gangrene, necrosis and loss of digits.

There are two types of Raynaud's disorders. The primary Raynaud's is idiopathic, arising spontaneously from an unknown and obscure cause. Prevention of known triggering factors itself is cure for Raynaud's disease. However the secondary type, also known as Raynaud's syndrome, arises due to umpteen underlying causes and diseases. Complete treatment of the underlying cause only can resolve the symptoms completely. Till such time, some temporary measures can be taken to alleviate the condition. Sometime the treatment measures go out of control and become serious, leading to necrosis and ulcers, even requiring amputation.

Self-help in Raynaud's disease treatment

Mental stress and cold are the main triggers for the primary type.Stress management for treatment
If the attack is due to mental stress or anxiety, positive thinking must be developed to control the situation. Relaxation exercises, yoga, deep breathing or meditation can bring about the relaxed feeling and relieve vascular constriction.Keeping warm
The affected person should move immediately to a warmer place. Wearing warm clothing and hat helps in the treatment. Hands and feet may be kept in a warm water bath and gently wiggled to restore circulation. If warm water is not immediately available, keeping the affected fingers in mouth, armpit or crotch will help. Rubbing the hands can improve circulation to the extremities. Swinging the arms for several minutes also can restore circulation.

Raynaud's treatment with medication

"Consult a qualified health professional before taking any medicine for Raynaud's disease".
Antidepressants:
If the triggering factor is mental stress, Fluoxetine, an antidepressant of the selective serotonin reuptake inhibitor (SSRI) class, may be prescribed, which is quite effective in controlling anxiety. There are other effective antidepressants available.
Calcium channel blockers:
Calcium channel blockers like diltiazem or nifedipine have been found to be effective in dilating the constricted blood vessels and useful in Raynaud's disease treatment.
Angiotensin II receptor antagonist:
Also known as angiotensin receptor blockers (ARBs), AT1-receptor antagonists or sartans, have been found to reduce the severity and frequency of Raynaud's disease attacks.
Alpha blockers:
α1-adrenergic blockers have been found to be effective in treatment.
Phosphodiesterase-5 inhibitors:
Sildenafil is found to improve the blood circulation to the affected digits.
Vasodilators:
Topical nitroglycerin is also relieves the vascular constriction.

Surgical treatment for Raynaud's disease

In rare cases when there is a fear of loss of digits, sympathectomy, is performed to save the fingers. The nerves stimulating the constriction of blood vessels are surgically severed. Microsurgery may be performed to bypass the affected arteries. To block the sympathetic nerves chemicals may be injected. There are some positive results with laser treatment for Raynaud's disease. If there is severe necrosis and gangrene, amputation of the digit has to be considered.

Alternative medicine for Raynaud's treatment

In a few experiments it is found that applying extract of Ginkgo biloba leaves reduces the frequency of Raynaud's attack. Fish oil supplements containing long-chain omega-3 fatty acids are effective in control of Raynaud's disease. However greater quantities (6.5 grams) are to be used.
Biofeedback is a process of mental control of physiological processes used in many disease treatments, initially using certain equipments. Eventually, this can be accomplished without the use of extra equipment. Temperature biofeedback is used by biofeedback therapists for treatment of Raynaud's disease. This helps in treatment to bringing the temperature of fingers under voluntary control.

Prevention of Raynaud's disease and emergency measures

Focusing on having a relaxed state of mind and relaxation exercises reduce anxiety and stress.

It is important to keep the whole body warm by wearing warm clothing to prevent episodes of Raynaud's disease.

Avoiding cold places and winter sports helps in treatment.

Cool drinks and cold food must be avoided.

Consuming hot beverages and hot food puts off attacks.

Avoiding chilly weather and not getting drenched in rain is necessary.

For Raynaud's disease treatment Keeping home warm and turning down air conditioner is necessary.

If the Raynaud's disease induced by any particular medicine, consult a physician for an alternative.

Certain medicines used for treatment of cold, hypertension and weight loss can worsen the Raynaud's disease.

Though several self-help measures and treatments may bring relief to the Raynaud's disease affected person, the underlying triggering factors must be completely addressed to prevent recurrence. Unfortunately patients afflicted by autoimmunity induced Raynaud's disease do not respond satisfactorily to treatments.